When a patient receives a prescription from a health care provider, they take the prescription to their pharmacy to be filled (or it may be faxed ahead in advance). Once the pharmacy receives the prescription, and prior to it being filled, it is typically submitted for approval by the customer's insurance. In this manner, assuming that the insurance approves the prescription, the pharmacist only charges the customer the amount of their co-pay, or whatever other amount remains after insurance pays its portion.
However, this process often does not run smoothly. If the prescription is rejected by the insurance (or other third party payer), the pharmacy will have to collect the entire amount for the prescription from the customer or attempt to overcome the rejection. Because pharmaceuticals are often very expensive (as are insurance premiums), customers will want their insurance to pay its share whenever possible. In some cases, the customer may forego the prescribed medication where insurance rejects it. Thus, efforts are made to try to overcome the rejection. Traditionally, this involves the pharmacist taking time to review the prescription, fix any obvious errors, and resubmit the information for approval. However, the pharmacist may have limited access to information needed to identify and/or correct errors. If their attempts fail, they may have to call the insurer directly. These activities take considerable time, have an unacceptable success rate, and slow down the service provided by the pharmacy.
Prescription formats and details vary, as do the requirements and protocols of the various different payers (insurers and other third parties), which leads to rejections. Rejections come in various formats, but typically have three components: a rejection message, an “additional message” and notes. This information ideally informs the pharmacy as to the reason for the rejection and what needs to be done to fix it. However, it is often missing information that must be acquired from various sources—some within the pharmacy and some outside of it. Attempting to correct these rejections and resubmit for approval is a drain on pharmacists and their staff, result in customer dissatisfaction through longer wait times and the like. Also, there is no systematic or logic-based methodology for addressing rejections, tracking prescriptions and attempts to correct them through the system, or learning from past errors. There is a need for a system that organizes, automates, and enhances/improves existing processes for handling payment requests on pharmacy prescriptions to help streamline the overall prescription fill process and free up pharmacists to perform their primary tasks.